Provider Demographics
NPI:1427409465
Name:LEROY-LONDON, TAMARA (LICSW)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:LEROY-LONDON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-3510
Mailing Address - Country:US
Mailing Address - Phone:617-825-9660
Mailing Address - Fax:617-288-7898
Practice Address - Street 1:637 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-3510
Practice Address - Country:US
Practice Address - Phone:617-825-9660
Practice Address - Fax:617-288-7898
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1219821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110152007AMedicaid